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Family Health Stressor Overweight & Obesity
Overweight and obesity is increasing in virtually
every ethnic, racial and socioeconomic population, in both
genders and in every age group (AOA, 2002) it is second
leading cause of preventable death in the United States,
exceeded only by smoking (AAHC, 2007). Quality of life
decreases and chronic medical conditions increase with
increasing body mass. Overweight and obesity is a serious
problem in the United States doubling in both children and
adults in the last twenty years (Gamm, Hutchison, Dabney, &
Dorsey, Vol.1, 2003). Obesity is a social problem affecting
well-being of individuals, families and society as a whole
(CDC, HC, AAG 2008). It now threatens to shorten the lives
of many people, is directly related to numerous health
complications, physical disability, reduced quality of
life, psychosocial issues and discrimination (Gamm,
Hutchison, Dabney, & Dorsey, Vol.1, 2003).
Population At Risk
All Americans, urban, suburban and rural at every age
and every socioeconomic level are at risk for issues
related to excess body mass. Between 1983 and 2003 Missouri
experienced large increases in overweight and obesity in
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every major maternal demographic (DHSS, 2004). Forty-
percent of Missouri children and adolescents are at risk of
becoming overweight or obese (Bihr & Klein, 2005), while
thirteen percent already are (Gamm, Hutchison, Dabney, &
Dorsey, Vol.1, 2003). As of 2008, 71.7 percent of adult
males and 56.9 percent of adult females in Missouri were
overweight or obese, above the national averages of 69.0
percent and 52.2 percent respectively (KFF, 2008).
Overweight and obesity is a serious issue resulting in
loss of physical functioning, loss of productivity, pain
and suffering, psychosocial issues, depression and
premature death (CDC, 2008). It is clear simply by the
magnitude of this issue every physical and mental health
practitioner should expect to interact with clients related
to the physical, emotional or social effects related to
overweight or obesity at some point in practice.
Cause & Complications
A persons body weight is a result of the complex
interaction of genes, metabolism, behavior, environment,
culture and socioeconomic status (CDC, 2007). Obesity has
been linked to substantially increased mortality risk from
all causes. Including arthritis, type 2 diabetes,
hypertension, birth defects, breast cancer, endometrial
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cancer, colon cancer, dyslipidemia, stroke, cardiovascular
disease, gallbladder disease, sleep apnea and respiratory
problems, infertility, obstetric and gynecological issues
and complications, urinary stress incontinence,
osteoarthritis and psychosocial disorders (CDC, 2008).
Complications and medical conditions as a result of excess
body weight are common and relatively easy to develop.
Gaining as little as five percent or 11 to 18 pounds over a
normal body weight can increase risk of type 2 diabetes and
heart disease. When BMI exceeds 30 the risk of death
related to obesity increases by 50% (AOA, 2002).
Adolescents who are overweight face increased health
risk, as excess body weight tends to persist into
adulthood. Chronic health conditions and increased risks
related excess adolescent body weight include
atherosclerosis, diabetes, coronary heart disease, hip
problems and gout (Gamm, Hutchison, Dabney, & Dorsey,
Vol.1, 2003).
Family Health Considerations
Overweight and obesity has dramatic implications for
the health of individuals, families and communities. Body
weight issues may be a primary, secondary or tertiary cause
of disability, stress, distress, depression or other
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psychosocial, emotional or familial issues related poor
health, disability of a family member, premature mortality,
and or familial conflict (AOA, 2002). Overweight and obese
individuals also often suffer stigma and discrimination
(Gamm, Hutchison, Dabney, & Dorsey, Vol.1, 2003) as a
result of American societies depreciation of the overweight
and obese and a pro-slender muscular bias (Swami, Furnham,
Amin, Chaudhri & Josht, 2008). Stigma and discrimination
suffered by one family member often affects the whole
family or extended family unit (Zastrow, 2007), and may
underlie issues prompting clinical intervention.
There has been a great deal of research related to
overweight and obesity over the last few years, but a clear
path to successful holist social level prevention remains
elusive. What is known at this time is that numerous
environmental and behavioral factors significantly
contribute to the imbalance that results in weight gain
leading to increasing body weight, overweight, obesity and
the psychosocial issues related to them for individuals and
families. Because behavior and environment contribute
substantially to weight issues it is in these areas the
most benefit can be gained (CDC, 2009).
Changes in micro and mezzo level cognitive, behavioral
and social relationships and settings have been shown to
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provide benefit (CDC, 2008). Between 300,000 and 600,000
lives could be saved in the United States each year if
Americans would maintain healthy body weights (AAHC, 2007).
The serious and far reaching changes within the social
environment have and continue to make it increasingly
difficult for individuals and families to engage in health
promoting behaviors including participating in daily
regular physical activity which has been found to
substantially contribute to the maintenance of a healthy
body weight (MMWR, 2003).
It is currently believed based upon previous research
and program efforts that for interventions to be successful
they must incorporate a decrease in fat and calorie intake
and an increase in physical activity across time. Changes
in multiple social settings increase success including
home, family, work, school and community. Macro level
societal changes such as media and healthcare policy would
also be beneficial in helping Americans lead healthier and
more physically active lives (Gamm, Hutchison, Dabney, &
Dorsey, Vol.1, 2003) and should be a focus for all
clinicians seeking to improve the psychosocial welfare of
Americans.
While there is compelling evidence that physically
active people are less likely to become obese (Shah, 2007)
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in 2001 less than half of the adults in the United States
were active enough to meet the recommendations for physical
activity consistent to reduce the risk premature mortality
(MMWR, 2003). As of 2007 only 32.8% of Missouri adults
engaged in regular, vigorous, sustained physical activity.
Clinical Considerations
The research has consistently shown that just 5%-10%
of body weight loss can ameliorate many of the chronic
medical conditions associated with overweight and obesity.
Small changes in multiple areas that are emotionally,
physically, economically and socially sustainable should be
emphasized (CDC, 2007). Compelling evidence that physically
active people are less likely to become obese (Shah, 2007)
and should be a primary emphasis in any holistic
intervention plan of treatment with a goal of 30 to 60
minutes of moderate to intense physical activity each day a
minimum of three days each week (AHA, 2006). Coupled with
reduced calorie and fat consumption and increased fruit,
vegetable and fiber consumption. In effect increasing
nutrients and activity while decreasing calories in order
to reach a total calorie deficit weekly or monthly as may
be appropriate based on client need and primary problem
presentation.
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It is critical practitioners be prepared and adept at
operating within a multidisciplinary team with the client
as a central figure if true long-lasting change is to be
maintained. It is critical that practitioners are acutely
aware of the pressures body weight and the stresses related
to overweight and obesity and related complication have on
clients and family systems. Especially in light of the fact
that eating disorders often go undetected and untreated
because most patients do not actively volunteer information
related to weight, food and eating behaviors and a vast
majority of clinicians across care fields fail to ask
(Schumann & Hickner, 2009). Overweight, obesity and related
psychosocial and medical complications must be considered
and assessed as a regular point of interest in any family
health assessment. It is currently estimated that as few as
10% of those who suffer with disordered eating and food
issues ever receive any treatment (Schumann & Hickner,
2009). In addition, to delving into familial patterns and
practices surrounding health including medical conditions,
home practices and compliance with medical and care
regimens. Data shows that family plays a role in
development of asthma and diabetes, a clear indication of
the importance of family influence on physical health and
well-being (Yuen, Skibinski & Pardeck, 2003).
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Biopsychosocial and biobehavioral treatments have been
found to be effective in the treatment of overweight and
obesity and may include gradually restricting and or
eliminating stimuli that elicit maladaptive eating patterns
and behaviors (Gatchel & Oordt, 2004). Family involvement
in the treatment of body weight issues and medical regimen
maintenance has been show to increase compliance and
promote weight loss (Yuen, Skibinski & Pardeck, 2003).
Client sensitivity to familial criticism are associated
with high rate of relapse (Yuen, Skibinski & Pardeck,
2003). Clinicians should explore how each individual and
family react to stress, the attitudes and behaviors
surrounding health services and practices, the relationship
between family functioning and individual well being
including the physical, mental, emotional and social
aspects (Yuen, Skibinski & Pardeck, 2003).
Gatchel and Oordt offer guidance for successful
collaboration with primary care providers suggesting a
three part process for treatment plan development for
overweight and obese clients including, classification of
degree of issue, the more severe the problem the more
aggressive and intensive the treatment. A stepped care
approach, least invasive, least expensive and least
dangerous treatments first, ranging from self-directed to
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commercial or behavioral programs to in-patient or surgical
interventions. All should include private counseling in
order to increase efficacy and long=term weight
maintenance. Selection of a specific program should be
based on individual needs and preferences of the client and
not on clinician preference or regimentation of services
(Gatchel & Oordt, 2004).
Dieting issues clinicians should be aware of include
the use of diet to achieve substantial weight loss for
those with substantial looming or advancing complications.
Very low calorie diets, 800 calories per day and low
calorie diets 800 to 1500 calories per day are now
considered safe for outpatient populations. Collaboration
with other professional should be emphasized as support and
oversight can improve outcomes and decrease complications
(Gatchel & Oordt, 2004). Mental health practitioners should
seek permission to discuss clients cases as may be
appropriate or necessary with physicians, dietitians or
other professionals with which the client is closely
working to increase client benefit and decrease conflicting
recommendations. It is critical that respectful mutuality
in professional relationships be cultivated in this type of
an arrangement ensuring the client is not faced with
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conflicting or competing orders or regimens that could
exacerbate client stress (Gatchel & Oordt, 2003).
When working with children and adolescents clinicians
must work within the family unit and often a multiple
disciplinary team in order to meet the unique challenges of
adolescents with body weight issues and complications.
Research has suggests that chaotic food and eating routines
can be targeted as a focus for behavior change. Finding
that ordering eating within the family context can be used
effectively to promote health within the family environment
(Kime, 2009). Ordered lifestyle as a basic framework,
including family members eating together in the same room
at a table without external influences, increasing the
inherent value of meal time as an occasion focusing on
mealtime and togetherness (Kime, 2009). In addition to
targeting individual and parenting behavioral based
practices to increase making fruits and vegetables easily
accessible, placing appropriately nutritious prepared
within easy reach in appropriate portion sizes, recognition
and conscious understanding that individuals and parents
have substantial influence over food availability within
the home and that availability and accessibility of foods
are strong predictors of consumption (Rhee, 2008). Physical
activity frequency, duration and intensity are also related
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to social environment and specific attention should be
focused on increasing physical activity frequency, duration
and intensity within the family system and not simply
focusing on the individual who has developed issues or
complications. The data clearly shows that risk factors
often impact the whole or extended family system (CDC,
2008).
Careful consideration and attention should be given to
increasing positive interaction and reducing criticism of
depressed children or adolescences with the body weight
issues or complications as depression often increases
vulnerability to family criticism and family criticism is
associated with high rates of relapse. Marital conflict
should also be addressed as it frequently accompanies
depression and can impair the functionality of families and
limit support available to children with chronic health
issues (Yuen, Skibinski & Pardeck, 2003).
In addition to children and adolescences, other
populations of special attention for clinicians should be
the aging and persons of color. The aging population was
previously believed to be at low risk for eating and weight
related disorders, but as the population of the United
States has aged, like wise has overweight and obesity
issues expanded to this population. Issues within the aging
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population may be compounded, especially for aging
overweight or obese women. As overweight and obese women
often bear the brunt of severe social criticism related to
body weight, often popularly characterized as diseased,
unhealthy, lazy, weak and or impulsive (Gamm, Hutchison,
Dabney, & Dorsey, Vol.1, 2003). As women age they are more
likely, as compared to aging males, to show a preference
for thinner bodies compounding the numerous physical
changes that accompany aging. (Ferraro at el. 2008).
Research has found the salience of body image as a
pervasive concern for women across the life cycle and is
often compounded by aging, with the increased likelihood of
weight related medical and health complications (Ferraro,
Muehlenkamp, Paintner, Wasson, Hager & Hoverson 2008), loss
of support systems through death or relocation and other
age related physical, social and environmental pressures.
American society powerfully and pervasively
stigmatizes the overweight and obese through a social
ideology that attributes negative life outcomes to negative
personal characteristics (Swami et al. 2008). Compounding
this slender bias is the youth culture, in effect doubling
the pressure of older women to meet social expectations of
slenderness (Swami, Furnham, Amin, Chaudhri & Josht, 2008),
and youth, all while the normal age related life cycle and
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role changes of aging continue to mount increasing pressure
for those at risk within this population. One critical
consideration for clinicians is the finding that overweight
older women have been found to be significantly more
concerned with their bodies than normal weight women of the
same age, this could reflect a logical understanding of the
health related risk surrounding overweight and obesity
rather than simply internalization of the slender social
standard (Swami et al., 2008). Clinicians should be aware
of this and assess older women presenting with body weight
related issues for psychosocial distress compounded by the
normal aging process and role change related to the family
life cycle being conscious to address any findings
appropriately (Carter & McGoldrick, 2005).
Research now suggests that body weight dissatisfaction
and assimilation of Western beauty ideals or thinness
cultural norms have been found at increasing rates in black
female student of divergent backgrounds both urban and
rural. Findings suggesting similar prevalence of hazardous
weight management practices, disordered eating attitudes
and behaviors, and retrained eating patterns, to white
groups (Senekal, Steyn, Mashego & Nel (2001). Problems with
body shape dissatisfaction, disordered eating behaviors and
attitudes and dietary restraint are highly interrelated and
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should be examined closely by clinicians (Senekal, Steyn,
Mashego & Nel (2001). The number of weight loss attempts
was found to be lower in black females they were found to
more often use hazardous methods (Senekal, Steyn, Mashego &
Nel (2001). Clinical consideration and investigation should
be detailed as to previous weight loss methods used, age
related developmental milestones, familial and social
internalization of idealized thinness, which may be
underlying womens weight loss attempts. Efforts should be
made to emphasize health rather than the thinness ideal and
the inherent value of every individual regard less of body
weight.
Another issue of concerning overweight and obesity
treatment is binge eating disorder (BED) which has been
found to be triggered by negative affective states and
dietary restraint related to weight loss efforts (Friedman
2008). Clinicians need to be cognizant of the recurrent
nature of BED and treat accordingly. Clinicians should
focus on acute episode behavioral techniques and relapse
prevention while encouraging and supporting clients to
adhere to calorie restricted dietary interventions and
regimens (Friedman, 2008). Careful assessment to determine
underlying issues including client feelings of being out of
control with food, eating until vomiting or feeling sick,
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food seeking behaviors including leaving the home to obtain
food for the purposes of binging (Friedman, 2008).
Cognitive behavioral therapy (CBT) or other behavior
modification interventions should be used to reduce
reoccurrence and relapse. Standard protocol for CBT for BED
has been found to be effective in treatment of BED, which
includes a physical and dietary assessment to rule out
medical causes or complication, dietary support and
nutrition therapy. Individual therapy, daily-self
monitoring, journaling and prescribed eating pattern to
reduce compulsive eating and removing emotional decision
making from eating schedule and food choice.
Psychoeducation to identify common cognitive distortions,
automatic thoughts and affective triggers and behavioral
strategies have been shown to be very useful in delaying
acting upon binge urges (Friedman, 2008). A useful tool in
relapse prevention can be the use of structured planned
binges suggestions include choosing in advance the time,
limiting the trigger foods to a total of 300 calories,
after dinner with at least one other person in the room
(Friedman, 2008). Planned binges serve to diffuse tension
related to not binging, removing the function of the binge
behavior reducing its desirability and allowing for
variety, making client dietary restrictions easier to
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adhere to, the ultimate goal of planned binges should be
one bi-weekly planned binge of 300 calories or less
(Friedman, 2008).
In addition to the numerous issues previously
discussed it is valuable to note that assessment of current
medication regimen is also of great value to a clinicians.
Numerous medications have weight gain as a well known side.
As well as there are several medications currently that
have been shown to benefit weight loss efforts and weight
maintenance Gatchel & Oordt, 2003). It can be of great
benefit to understand and examine current medical regimens
with a holistic understanding of the side effects, intended
or unintended, as well as the pharmaceutical resources
available to assist clients in meeting their weight loss
goals.
Overweight and obesity is increasing in virtually
every ethnic, racial and socioeconomic population, in both
genders and in every age group (AOA, 2002). As the second
leading cause of preventable death in the United States,
(AAHC, 2007) clinicians must be aware of the challenges and
resources available to serve this increasing and
increasingly vulnerable population. With emphasis on
quality of life and amelioration of chronic medical
conditions mental health practitioners can serve a vital
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function in the treatment of the excess body weight and
obesity.
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